Ensures that records are coded within 48 hours of completion of dictation, excluding weekends and holidays.
Reviews documentation for completion and accuracy to ensure proper assignment of CPT, ICD-9, and HCPCS codes and modifiers.
Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record.
Codes diagnoses and procedures on clinical summary agree with physician's preference 100% of the time.
Refers medical record to director, If there is a question regarding the diagnoses/codes.
Utilizes computerized coding/abstracting equipment.
Codes all diagnoses/procedures in accordance to ICD-9-CM coding principles and the Coding Manual.
Logs diagnoses, procedures and other abstracting data on worksheet for abstractor to input into computer and/or inputs diagnoses, procedures and other abstracting data into computer themselves.
Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.
Maintains 99% rate of information correctly abstracted.
Reviews coding periodicals within seven (7) days of receipt.
Notifies director whenever work is more than 48 hours behind work deadline.
Assists the director with state requirements and reports.
Acts as a resource person to BMG staff and physicians for coding and may provide education regarding coding changes/issues.
Must be familiar with all medical record and coding requirements.
Maintains a good working relationship within the department, other departments and medical staff.
Willing to accept additional assignments.
Performs performance improvement functions through data collection and documentation review.
Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.
Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.